Provider Demographics
NPI:1124374798
Name:REHOBOTH PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:REHOBOTH PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEDOLAPO
Authorized Official - Middle Name:ADESHOLA
Authorized Official - Last Name:OLURINDE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:347-351-4970
Mailing Address - Street 1:24104 148TH RD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3249
Mailing Address - Country:US
Mailing Address - Phone:347-221-1646
Mailing Address - Fax:718-481-7929
Practice Address - Street 1:598 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1507
Practice Address - Country:US
Practice Address - Phone:347-221-1646
Practice Address - Fax:718-481-7929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023029174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1508092446Medicaid